Pirozzi et al. Critical Ultrasound Journal 2014, 6:5http://www.criticalultrasoundjournal.com/content/6/1/5

ORIGINAL ARTICLE Open Access

Immediate versus delayed integrated point-of-care-ultrasonography to manage acute dyspnea inthe emergency departmentConcetta Pirozzi1, Fabio G Numis1*, Antonio Pagano1, Paolo Melillo2, Roberto Copetti3 and Fernando Schiraldi1

Abstract

Background: Dyspnea is one of the most frequent complaints in the Emergency Department. Thoracic ultrasoundshould help to differentiate cardiogenic from non-cardiogenic causes of dyspnea. We evaluated whether thediagnostic accuracy can be improved by adding a point-of-care-ultrasonography (POC-US) to routine exams and ifan early use of this technique produces any advantage.

Methods: One hundred sixty-eight patients were enrolled and randomized in two groups: Group 1 received animmediate POC-US in addition to routine laboratory and instrumental tests; group 2 received an ultrasound scanwithin 1 h from the admission to the Emergency Department. The concordance between initial and final diagnosis andthe percentage of wrong diagnosis in the two groups were evaluated. Mortality, days of hospitalization in EmergencyMedicine department and transfers to other wards were compared. Sensitivity and specificity of the routine protocoland the one including ultrasonography for the diagnosis of the causes of dyspnea were also analyzed.

Results: Eighty-eight patients were randomized in group 1 and 80 in group 2. The concordance rate between initialand final diagnoses was significantly different (0.94 in group 1 vs. 0.22 in group 2, p < 0.005). The percentage of wronginitial diagnosis was 5% in group 1 and 50% in group 2 (p < 0.0001).

Conclusions: Adding POC-US to routine exams improves the diagnostic accuracy of dyspnea and reduces errors in theEmergency Department.

Keywords: Point-of-care-ultrasonography; Dyspnea; Diagnostic accuracy; Emergency Department

BackgroundDyspnea is a subjective feeling of difficult, labored, oruncomfortable breathing and is among the most fre-quent complaints in patients admitted to the EmergencyDepartment (ED). A rapid and correct diagnosis of theunderlying cause is mandatory to provide early and tar-geted treatments. Discriminating between causes of dys-pnea through clinical examination and initial routineapproach, including history, electrocardiography (ECG)and laboratory results, may be inconclusive [1-3]. Chestradiograph (CXR) is currently the first routine imagingexamination recommended for dyspneic patients: it isrelatively easy to perform in ED and offers an immediate

* Correspondence: fabionumis@libero.it1Emergency Medicine Department, San Paolo Hospital, Via Terracina 219,Naples 80125, ItalyFull list of author information is available at the end of the article

© 2014 Pirozzi et al.; licensee Springer. This is aAttribution License (http://creativecommons.orin any medium, provided the original work is p

full-picture of the thorax. On the other side, CXR hasseveral limitations. The major technical disadvantagesare the limits of resolution, inability to visualize vascularstructures and visualization of three-dimensional struc-tures on a two-dimensional plane. Moreover, most of thetimes it is impossible to acquire posteroanterior and lat-eral projection in supine patients in the emergency set-ting; furthermore, ionizing radiation can cause damageto pregnant women. Finally, the report is not immedi-ately available, and, above all, it has limited accuracy indetecting some diseases [4].Another puzzling issue is that a valuable percentage of

patients, almost elderly, show more than one cause ofdyspnea [5,6].Definitely, all these factors make the diagnostic ap-

proach challenging to dyspneic patients in ED.

n open access article distributed under the terms of the Creative Commonsg/licenses/by/2.0), which permits unrestricted use, distribution, and reproductionroperly cited.

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Thoracic ultrasonography has been successfully intro-duced as a new and promising instrument for the diagno-sis of different pulmonary diseases [7,8], and its ability todiscriminate between cardiogenic and non-cardiogenicdyspnea is widely demonstrated in many valuable works[8-14].However, thoracic ultrasonography alone could not cor-

rectly diagnose some causes of dyspnea and acute respiratoryfailure, such as pulmonary embolism and non-cardiogenicpulmonary edema (ARDS). In this last case, althoughsome ultrasonography characteristics enable a clear dis-tinction from cardiogenic edema [12], integrating the in-formation derived from ultrasound assessment of theheart, may allow its complete definition and distinction.The purpose of our study was to evaluate if a protocol in-

cluding the standard diagnostic process (i.e. ABG, CXR,ECG, biochemical exams) and point-of-care-ultrasonography(POC-US) in ED would improve the accuracy of theemergency physician (EP) in the approach to acute undif-ferentiated dyspnea. Moreover, we attempted to explore ifan immediate POC-US gives some advantages over a de-layed ultrasonography evaluation of dyspneic patients. Oursecondary purpose was to evaluate if the timing of theultrasound could affect the number of dead, transferred ordischarged patients and the days of hospitalization in theEmergency Medicine department.

MethodsThis was a single-center randomized prospective studyabout the use of POC-US in patients in ED presentingwith undifferentiated dyspnea. All patients gave their in-formed consent to ultrasound examination (relatives con-sented for uncapable patients). The study was conductedin accordance to the principles of the declaration ofHelsinki and approved by the Hospital Ethical Committee.The study was performed between February and July

2012 in the ED (including also Emergency Medicine div-ision) of the San Paolo Hospital, Napoli. We included180 patients admitted to the ED (after pre-hospital carefor some of them) because of complaining dyspnea, de-fined as either the sudden onset of shortness of breathwithout history of chronic symptoms or as increase inthe severity of the chronic shortness of breath. Exclusioncriteria were age <18 years, trauma, and ST elevationand myocardial ischemia.The patients were enrolled only when one of the three

investigators was present, although bedside ultrasonog-raphy is routinely performed in our ED by a consistentnumber of physicians.The three participating investigators were two emer-

gency residents and one attending physician, all well-trained in emergency ultrasonography.Patients were randomly assigned to group 1 or group 2.

Group 1 received POC-US immediately, before any treatment

(except for pre-hospital medications, if needed); group 2followed the standard protocol of dyspnea and receivedPOC-US within 60 min from the admission to the Emer-gency Department (Figure 1).At time 0, medical history, medical treatment, signs and

symptoms, 12-lead ECG, samples for standard blood tests(including troponin-T, D-dimers, WBC count and ultra-sensitive C-reactive protein) and blood gases (ABG) weretaken from all patients, both in groups 1 and 2. CXR wasobtained for all patients immediately after the physicalexamination and/or POC-US or after the initial treatment,as needed (although we do not have data on exact timingof CXR, we can assume that it was obtained between 15and 20 min from the first medical contact).In group 1, POC-US was performed only by one of the

investigators.POC-US exams were completed in the maximum of

8 min and were performed during nurse’s maneuvers. Thephysician-investigator was requested to indicate the initialdiagnosis, derived from history and medical examination,ultrasonography, ABG, ECG and CXR result, within30 min from fist medical contact (the adequate time toobtain CXR results).In group 2, the physician who took in charge the pa-

tient was not a study member and made the initial diag-nosis on the basis of history, medical examination, ABG,ECG and CXR result (within 30 min, as for group 1).The POC-US in group 2 was performed for all patients

by one of the three investigators as soon as one of the threewas available, almost after the CXR execution, thereforelikely between 20 to 60 min after the admission in the ED.In this last case, the investigator was blinded to the routinetests’ results before carrying out the ultrasound examin-ation. After the POC-US, in group 2, the treating doctor re-vised the initial diagnosis and the therapeutic strategy, asnecessary, according to ultrasonography findings, definingan intermediate diagnosis. The EPs were asked to indicatetheir initial diagnosis on a given form, choosing among sixpossibilities (Table 1), within 30 min from the first medicalcontact (an adequate time frame to obtain CXR results,given that the radiology is close to the emergency room).At the end of the hospital course, the patient’s charts werereviewed by two independent EPs, blinded both to ultra-sonography findings and to the diagnostic hypothesis madeby the investigators or the treating physicians. The finaldiagnosis was determined according to the standard criteriaof each disease (Table 2) [15-20] by the two EPs, if theyagreed independently on a diagnosis. If they disagreed, athird physician was consulted. The lists of possible initial,intermediate and final diagnoses coincide (Table 1).When more than one cause of dyspnea was found in the

same patient (mixed diagnosis), we considered as maincause of acute dyspnea/respiratory failure the patho-logical process that worsened the clinical situation (i.e.

Figure 1 Study design. ECG, electrocardiogram; CXR, chest radiograph; ABG, arterial blood gases.

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in a patient with AHF and pneumonia, although pneu-monia could trigger the dyspnea, AHF is the clinicalsyndrome determining the respiratory failure).The POC-US included lung, cardiac, inferior vena cava

(IVC) and inferior limb vein compressive ultrasonog-raphy (CUS). A commercially available portable echogra-phy equipment (Mylab 30, Esaote Medical System, Genoa,Italy) was used to perform POC-US. Lung ultrasonog-raphy was performed with a 3.5 MHz convex probe,according to the eight-region technique [21]. A 2.5 to3.5 MHz cardiac transducer was used in subcostal (SC)view for IVC evaluation and in SC and apical four-chamber (AP4) views for cardiac evaluation. Each cardiacexam was conducted using both views, except if one ofthem was not adequate. A qualitative eyeballing evaluation

Table 1 Causes of dyspnea and their occurrence

Number/percentage

Acute heart failure (AHF) 64/38

Acute exacerbation of COPD (ECOPD)/asthma 53/31.5

Pneumonia 51/30.3

Acute respiratory distress syndrome (ARDS) 14/8.3

Massive pleural effusion 7/4.1

Acute pulmonary embolism 9/5.3

of the ejection fraction of the left ventricle (LV) wasadopted [22].A qualitative evaluation of the right ventricle (RV) dimen-

sion was used, considering as abnormal a RV/LV end dia-stolic diameter >0.9 in the AP4 view and >0.7 in the SCview [23], or a normal RV size as 60% of the LV size at theend diastole (that is a valid criterion both for AP4 and sub-costal views). RV impaired function was estimated by re-duction of contractility and movement of the RV free wallin the AP4 and SC views [24]; the absence of paradoxicalinterventricular septal motion was considered normal [24].The IVC maximum diameter and the percentage of

respiratory collapsibility (caval index) were recordedfrom SC view, 2 cm caudally from the junction of theright atrium, in order to estimate CVP: the combinationof diameter >2 cm and excursion <50% was consideredsignificant for a pressure >10 mmHg, while a diameter<2 cm together with an excursion >50% was diagnostic fora CVP <10 mmHg [23,25,26].A 7.5-mHz linear probe was used for CUS of the groin

and calf veins. All the ultrasonography images weresaved on a hard disk.The POC-US patterns used to define each clinical syn-

drome are resumed in Table 3.The concordance between initial and final diagnosis in

both groups 1 and 2 was analyzed by Cohen’s κ test.

Table 3 POC-US patterns and the correspondingcombination of ultrasonography findings

POC-US pattern Signs

AHF Interstitial lung syndrome (the presenceof multiple diffuse bilateral B-lines indicatesinterstitial syndrome) with reduced EF ofthe left ventricle or preserved EF withdiastolic dysfunction

Pneumonia Subpleural echo-poor region or one withtissue-like echo texture, with additional signssuch as air/fluid bronchograms and adjacentB-lines (focal interstitial syndrome)

ARDS Interstitial lung syndrome (the presence ofmultiple diffuse bilateral B-lines indicatesinterstitial syndrome), with non-homogeneousdistribution of B-lines and spared areas, andnormal systolic and diastolic function of theleft ventricle

Massive pleural effusion Anechoic space between parietal and visceralpleural and respiratory movement of the lungwithin the effusion

Possible pulmonaryembolism

Dilated, hypokinetic RV with systolic septaldyskinesia plus dilated IVC with lowcollapsibility index (only found in massive orsub-massive pulmonary embolism) andeventually positive CUS of the groin orcalf veins

Table 2 Six possible causes of dyspnea and theirdiagnostic criteria

Respiratory failure pattern Diagnostic criteria

AHF Signs and symptoms of heart failurepreserved or reduced systolic functionof the left ventricle, CXR congestion

Acute exacerbation of COPDand asthma

History of COPD or asthma, typicalfindings at lung examination, airflowlimitation, not fully reversible in COPD,fully reversible in asthma

Pneumonia Fever, cough, leukocytosis, rales orabolished vesicular murmur, pulmonaryinfiltrate at CXR, positive cultures(eventually)

ARDS Acute presentation within 1 week of aknown clinical insult or new/worseningrespiratory symptoms; chest imagingwith bilateral opacities-not fullyexplained by effusions, lobar/lungcollapse, or nodules; respiratory failurenot fully explained by cardiac failureor fluid overload; PiO2/FiO2 < 200

Massive pleural effusion Vesicular murmur abolished at lungauscultation and dullness at percussion,massive pleural effusion at CXR or US

Acute pulmonary embolism Signs and symptoms, prediction rulesindicating high probability; multidetectorcomputed tomography positive forpulmonary embolism; dilated,hypokinetic right ventricle withpressure overload signs (when theembolism determines a significativelyhemodynamic impairment)

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The number of incorrect initial diagnosis in groups 1and 2 was compared by Fisher’s test (p < 0.05 was con-sidered significant).Continuous variables were summarized as mean ± stand-

ard deviation and compared using the Student’s t test orFisher’s test as adequate. Categorical variables were pre-sented as frequencies and percentages and compared with ×2 tests. A p value of <0.05 was considered statisticallysignificant. All calculations were performed with SPSSsoftware, version 14.A Student’s t test or a Fisher’s test, as adequate, was

used for the comparison between the two groups in termsof days of hospitalization and deaths in the EmergencyMedicine department, patients discharged or transferredto ICU and General Medicine wards.

ResultsOne hundred sixty-eight patients made the final studysample; 88 were included in group 1, 80 in group 2.The two groups were well-matched for demographicand clinical characteristics (except for HR and RRwhich resulted significatively higher in group 2) and forprevious medical history (clinical, demographic and la-boratory characteristics showed in Table 4). All thePOC-US exams were completed in the maximum of8 min.In group 2 half of the diagnoses changed after POC-

US: the AHF was the most frequently changed diagnosis(25 out of 50, 50%); 48% of them were changed in pneu-monia; 20% in ECOPD; 16% in ARDS; 12% in pulmonaryembolism; 4% in massive pleural effusion. Among 23 ini-tial diagnosis of ECOPD, 44% of them were modifiedafter POC-US; 40% in pneumonia, 30% in AHF 30% inpulmonary embolism. Only one of the four initially diag-nosed pneumonia was changed in AHF.The Choen’s kappa between the initial (derived from

standard exams and POC-US in group 1 and fromstandard exams alone in group 2) and final diagnosiswas 0.94 (error 0.03; 95% confidence interval (CI) 0.88to 1.00, p < 0.0001) in group 1, 0.22 (error 0.07; 95% CI0.08 to 0.37; p = 0.006) in group 2.The overall concordance between the diagnoses made

after POC-US (initial diagnosis for group 1 and inter-mediate diagnosis for group 2) with final diagnoses was0.95 (error 0.02; 95% CI 0.92 to 0.99, p < 0.0001). Thefrequency of incorrect initial diagnosis in group 1 wassignificantly lower than in group 2: 5% (4 out of 88) ver-sus 50% (40 out of 80), (Fisher’s test p < 0.0001).Six main ‘final’ diagnostic categories were selected; their

occurrence in the total population is shown in Table 1.We did not find spontaneous pneumothorax cases in

our case series.Thirty-one patients (18.4%) in the whole population

had more than one diagnosis, but only the pathological

Table 4 Patients’ characteristics

G1 G2 P value

Age (years) 74.3 ± 11.4 74.5 ± 12.7 0.9

BMI (kg/m2) 28.5 ± 3 29 ± 3.4 0.3

Heart rate (bpm) 96.6 ± 20.8 110.6 ± 24 <0.05

Respiratory rate (bpm) 28.5 ± 5.8 30.4 ± 5 <0.05

SBP (mmHg) 148 ± 33 155 ± 37 0.19

DBP (mmHg) 85.6 ± 17.4 88 ± 18 0.38

pH 7.38 ± 0.1 7.37 ± 0.16 0.7

pCO2 (mmHg) 48.5 ± 17.5 44.1 ± 15.8 0.09

pO2 (mmHg) 63.8 ± 20.5 63.8 ± 28 1

FiO2 (%) 27.3 ± 11.6 25.6 ± 11.9 0.18

SpO2 (%) 87.3 ± 9.8 88 ± 8.4 0.6

PaO2/FiO2 255 ± 89 260 ± 87 0.7

HCO3− (mmol/L) 27.4 ± 6.8 26 ± 6.2 0.16

Lactate (mmol/L) 2.03 ± 2.2 2.4 ± 1.9 0.24

Troponin-T (ng/mL) 0.15 ± 0.64 0.08 ± 0.15 0.34

CRP (mg/dL) 4.3 ± 7.3 6.8 ± 9.1 0.05

WBC (×103/mL) 9.7 ± 4.8 10.6 ± 12 0.5

D-dimers (ng/dL) 1,175.3 ± 1,351 1,991 ± 1,039 0.9

COPD (%) 59 46 0.48

Renal failure (%) 23.8 22.5 0.83

Ischemic heart disease (%) 50 36 0.07

Heart failure (%) 22,7 20 0.76

Cerebral vasculopathy (%) 30 32.5 0.56

Diabetes (%) 25 27.5 0.7

Atrial fibrillation (%) 18 20 0.76

BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic bloodpressure; CRP, C-reactive protein; WBC, white blood cell; COPD, chronicobstructive pulmonary disease.

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process responsible for the precipitation of the clinicalscenario was considered in the statistical analysis.There was no significant difference in clinical out-

comes included in the secondary purpose between thetwo groups (Fisher’s test p = 0.76 for deaths in Emer-gency Medicine, patients discharged or moved fromEmergency Medicine to ICU or general medicine wards;the number of days in Emergency Medicine for patientsin group 1 was 4.0 ± 2.0 days vs. 4.4 ± 2.1 days in group2; t test p = 0.24).We analyzed the sensitivity and specificity of the

standard protocol and the standard protocol plus POC-US one for the diagnosis of each cause of dyspnea as re-ported in Table 5.

DiscussionThis study tested the hypothesis that a POC-US protocolwould increase the EP’s diagnostic accuracy in identifying

the correct cause of symptomatic dyspnea in ED. If theultrasound examination is performed at the same time ofthe visit in ED, the possibility of identifying the right causeof dyspnea is definitely higher than that given by thestandard routine tests only. Although we could not find adifference in the clinical outcomes between the twogroups of patients (immediate vs. delayed POC-US), thereduction of incorrect diagnosis after the first medicalevaluation in the group receiving immediate POC-US jus-tifies the use of ultrasound as soon as possible.It was reported that lung ultrasound alone, or combined

with N-terminal pro-BNP [8-14] and echocardiogra-phy [27], shows high diagnostic accuracy for differenti-ating cardiogenic from respiratory causes of dyspnea.Lichtenstein has proven the relevance of the BLUEprotocol in the diagnosis of acute respiratory failure inICU patients [28]. A recent study reports a higher ac-curacy of the lung-cardiac-inferior vena cava integratedultrasound than the lung ultrasound alone or combinedwith BNP, only in discriminating AHF from pulmonarycauses of dyspnea [29].To our knowledge, there are few data in literature sup-

porting the use of POC-US integrated with standardexamination in dyspneic patients in ED not only to dif-ferentiate between AHF and ECOPD but also to rightlyidentify the pulmonary diseases potentially involved.Our data confirm previous reports about the inad-

equacy of physical examination, CXR, ECG and ABG re-sults alone in obtaining the right diagnosis in a givenpercentage of cases [6,30,31].However, in our case series, the inaccuracy of initial

diagnosis in group 2 derived from the traditional ap-proach alone (before a delayed POC-US) is definitelylower than in other series. We think that the main rea-son of the low accuracy could be linked to the high per-centage of elderly people with comorbidities among thesubjects considered (mean age 74 years).As previously reported, in elderly patients, cardiac and

respiratory diseases frequently coexist; more than oneacute cause of dyspnea is frequently found and moreoverthey usually have atypical clinical presentation, such aswheezing in AHF (cardiac asthma) or lack of infectioussigns in pneumonia or non-respiratory symptoms in infec-tious disease [6]. Therefore, inappropriate initial treatmentoccurred in one third of the elderly people with acute re-spiratory failure, together with doubled in-hospital mortal-ity, as compared to patients that received an appropriatetreatment [6].Even more, in these patients, a POC-US approach

seems to be necessary to minimize diagnostic errors andto supply the best medical treatment.Actually, our percentage of errors using the traditional

approach to dyspnea was higher than the one describedby Ray et al. [6] in elderly people.

Table 5 Sensitivity and specificity of POC-US and standard protocol in diagnosis of acute dyspnea

After POC-US (G1 + G2)a Standard protocol (G2)a After POC-US (G2)a

Diagnosis Sensitivity (%) Specificity (%) Sensitivity (%) Specificity (%) Sensitivity (%) Specificity (%)

AHF 100 99 78.2 67.7 100 98.4

ECOPD/asthma 93 99 55.5 90.9 94.4 100

Pneumonia 92 98 14.2 97.1 93.3 98.5

ARDS 100 99 16.6 100 100 100

Massive pleural effusion 100 100 16.6 100 100 100

Acute pulmonary embolism 89 100 0 98.8 83.3 100a The diagnosis after POC-US is the initial diagnosis for group 1 (G1) and the intermediate diagnosis for group 2 (G2), the diagnosis after standard protocol is theinitial diagnosis for G2. AHF, acute heart failure; ECOPD, exacerbation of chronic obstructive pulmonary disease; ARDS, acute respiratory distress syndrome.

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There are, maybe, two other factors that could explainthis gap between evidences and our results.The first one is probably the poor quality of CXR in

our center: the X-ray room is next to the emergencyroom, so there is only a little delay in performing theexam, but almost all the CXRs are obtained in antero-posterior projection only, in supine patients, because ofdifficulties in positioning them (elderly people are oftennon-collaborating and sometimes obese or neurologic-ally compromised). So the quality of the exam is ser-iously affected and the sensitivity limited.The second cause of such a low accuracy is maybe the

lack of homogeneity among doctors in our ED, asregards to the specialty and the clinical experience andthe lack of enough time, because of high flow of patientsin the ED. But we could only speculate about and surelynot eliminate these factors: selecting some physiciansonly to participate to the study could uniform medicalskills, but should lead, of course, to a difficulty in obtain-ing an adequate sample of patients.So we can say, only by assumption that the low accuracy

of standard diagnostic approach reflects both the difficultieslinked to elderly people management and the limits due tomedical skills and lack of time in the emergency setting.By the way, according to current literature, our results

show that the sensitivity towards causes of dyspnea ofthe protocol including the POC-US is superior to theone with routine exams only. Previous studies showedthat LUS has a better diagnostic performance than CXRin dyspneic and ICU patients [32,33], suggesting thatlung ultrasound could replace CXR in ED. This last issueis also supported by a recent observational analysis,reporting that the clinical value of ‘on-demand’ individ-ual CXRs was markedly higher than that of ‘daily rou-tine’ CXRs, both for mechanically and non-mechanicallyventilated patients [34].Our study has surely some limitations. First of all, this is

a single-center study, with a small number of patients, en-rolled by only three EPs trained in ultrasonography. Be-cause of the small sample size, some causes of dyspnea

resulted in low recurrence, limiting the reproducibility ofdata relative to the ability of ultrasound in detecting them.Secondly, we could not find in our population a bene-

fit of immediate versus delayed POC-US on clinical out-comes, such as in-hospital mortality.Thirdly, some may argue that performing ultrasonography

after an initial treatment could influence some ultrasonog-raphy pathologic findings, because of their resolution. Thisshould be true for some cases of cardiogenic pulmonaryedema, although it is described that almost 2 h are necessaryto appreciate B-lines resolution after medical or continuouspositive airway pressure (CPAP) therapy [35,36].Fourthly, the ultrasound protocol used in this study

requires knowledge of cardiac, thoracic and veins ultra-sonography. This surely requires a special training, but itis elsewhere described that each single component ofthis protocol can also be performed by emergency physi-cians with limited training [37,38].Despite these limitations, we believe that this study

strongly supports the routine use of a POC-US protocol,including examination of lung, heart, inferior vena cavaand lower limb veins, together with routine exams, assoon as patients come to ED complaining of dyspnea.Additional research on larger populations could be

useful to evaluate the relationships between timing ofPOC-US in dyspnea in ED and patient’s main outcomes,and the impact on dyspnea associated costs, given theability of early integrated ultrasound to reduce the needof additional, more sophisticated tests, in some challen-ging clinical scenarios.

ConclusionsAdding POC-US to routine exams can really improve diag-nostic accuracy in patients complaining of dyspnea and canreduce errors in the ED, although there is no benefit of im-mediate versus delayed POC-US on clinical outcomes.

AbbreviationsABG: arterial blood gases; AHF: acute heart failure; AP4: apical 4 chamber;ARDS: acute respiratory distress syndrome; CUS: compressive ultrasonography;CXR: chest x-ray; ECG: electrocardiography; ECOPD: exacerbation of chronic

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obstructive pulmonary disease; ED: Emergency Department; EP: emergencyphysician; IVC: inferior vena cava; LV: left ventricle; POC-US: point-of-careultrasound; RV: right ventricle; SC: subcostal.

Competing interestThe authors declare that they have no competing interests.

Authors’ contributionsCP conceived the study, selected patients, performed ultrasound, supervisedthe data collection and drafted the manuscript. FN conceived the study,selected patients, performed ultrasound, approved and revised themanuscript. AP selected patients, performed ultrasound, supervised datacollection, approved and revised the manuscript. FS and RC managed thedata, including quality control, contributed substantially to manuscriptrevision. PM provided statistical advice on study design and analyzed thedata. All authors read and approved the final manuscript.

AcknowledgementsWe acknowledge Dr. Francesco Longo from San Paolo Hospital Napoli(echocardiographer in our institution, certified as instructor in CriticalUltrasound by SIMEU) for his supervision on ultrasound examinations.

Author details1Emergency Medicine Department, San Paolo Hospital, Via Terracina 219,Naples 80125, Italy. 2Multidisciplinary Department of Medical Science, SecondUniversity of Naples, Via S. Pansini 5, Naples 80131, Italy. 3EmergencyMedicine Department, Latisana Hospital, Cassacco, Udine 33010, Italy.

Received: 14 July 2013 Accepted: 8 April 2014Published: 27 April 2014

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doi:10.1186/2036-7902-6-5Cite this article as: Pirozzi et al.: Immediate versus delayed integratedpoint-of-care-ultrasonography to manage acute dyspnea in theemergency department. Critical Ultrasound Journal 2014 6:5.

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